Self-expanding metallic stent for the palliation of malignant esophageal obstruction complicated by vertebral erosion and esophagorespiratory fistula

Tracheal penetration and tracheoesophageal fistula caused by an esophageal self-expanding metallic stent

Tracheal penetration of esophageal self-expanding metallic stents (SEMS) with/without tracheoesophageal fistula (TEF) formation is a rare occurrence. We report the case of a 66-year-old female patient with advanced esophageal squamous cell carcinoma who had undergone palliative esophageal stenting on three occasions for recurrent esophageal stent obstruction. On evaluation of symptoms of breathing difficulty and aspiration following third esophageal stent placement, tracheal erosion and TEF formation due to the tracheal penetration by esophageal stent were diagnosed. The patient was successfully managed by covered tracheal SEMS placement under flexible bronchoscopy.

Esophageal stents for malignant strictures close to the upper esophageal sphincter

BACKGROUND

Self-expanding stents are a well-accepted palliative treatment modality for strictures resulting from esophageal carcinoma. However, the use of stents close to the upper esophageal sphincter (UES) is considered to be limited by patient intolerance caused by pain and globus sensation and an increased risk of complications, particularly tracheoesophageal fistula formation and aspiration pneumonia.

OBJECTIVE

Our purpose was to determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the UES.

DESIGN

Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006.

SETTING

Single university center.

PATIENTS

Patients with primary esophageal carcinoma (n = 66) or recurrent cancer after gastric tube interposition (n = 38) within 8 cm distance distal of the UES. Twenty-four (23%) patients also had a tracheoesophageal fistula.

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by chi(2) test, Kaplan-Meier curves, and log-rank testing.

RESULTS

Mean distance from the UES to the upper tumor margin was 4.9 +/- 2.6 cm and to the upper stent margin 3.1 +/- 2.3 cm. The procedure was technically successful in 100 of 104 (96%) patients. Fistula sealing was achieved in 19 of 24 (79%) patients. After 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34 of 104 (33%) patients. Of these, major complications (aspiration pneumonia [9], hemorrhage [8], fistula [7], and perforation [2]) occurred in 22 (21%) patients, whereas pain after stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue ingrowth or overgrowth (n = 10), food bolus obstruction (n = 7), stent migration (n = 3), or other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Eight (8%) patients complained of globus sensation; however, in none of the patients was stent removal indicated.

LIMITATIONS

Retrospective design.

CONCLUSIONS

Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. On the basis of these results, stent placement may be considered for palliation in this group of patients with an otherwise dismal prognosis.